Confusion among prison staff enabled inmate to take his own life, watchdog finds
All prisoners on a Special Observation List are required to be checked every 15 minutes with the assistant chief officer in charge of each division to ensure that officers in charge of landings are in possession of the latest copy of the Special Observation List at the start of each tour of duty. File picture
Confusion among prison staff about the status of a prisoner who was found hanging in his cell meant he was not checked every 15 minutes as required, an investigation by the prison watchdog has revealed.
A report by the Office of the Inspector of Prisons (OIP) into the death of the prisoner at the Midlands Prison in Portlaoise three years ago found conflicting reports between an assistant chief officer and prison officers over whether staff on the prisoner’s landing had been provided with a list of inmates who had been placed under special observation.
All prisoners on a Special Observation List are required to be checked every 15 minutes with the assistant chief officer in charge of each division to ensure that officers in charge of landings are in possession of the latest copy of the list at the start of each tour of duty.
The unnamed prisoner, who was scheduled for release on March 14, 2019 with remission, was found in an unresponsive state in his cell at 4pm on February 5, 2019. The 43-year-old inmate had been in continuous custody for three months at the time of his death.
The OIP report revealed he had been placed on protection from January 20, 2019, at his own request over fears that his life was under threat from other prisoners after he had refused to bring contraband into the jail for unnamed persons.
He had also requested a transfer to a different prison but was advised the request would be considered further following completion of pending appearances before Kilkenny Circuit Court.
The report showed a prison chaplain who spoke with the prisoner on the day before his death had raised concerns about his well-being with a number of prison staff, including a doctor and the chief nurse officer, which resulted in him being placed on the Special Observation List at 7pm that evening.
He was subsequently found with a ligature around his neck at 4pm on February 5, 2019. Attempts by prison nursing staff and doctors to resuscitate him proved unsuccessful and he was pronounced dead at 4.25pm.
The report noted the deceased had a history of polysubstance abuse and was on methadone at the time of his death as well as attending addiction services in the prison. Medical staff reported that he suffered from depression and had a history of deliberate self-harm.
The OIP said the assistant chief officer reported generating a Special Observation List on which he recalled seeing the prisoner’s name after coming on duty at 7.30pm on February 4, 2019.
However, three prison officers who were on duty on the prisoner’s landing over the following 24 hours each claimed they had not been provided with any list.
A night guard told the OIP he had not received any list while on duty, even though he signed a journal in which he stated that all prisoners had been checked “paying particular attention to those on the Special Observation List.” CCTV footage showed the night guard checked the prisoner at regular intervals during the night but not every 15 minutes.
The night guard said the prisoner was awake in his cell up to 7am and had replied he was fine but just could not sleep when asked if he was OK.
Two other prison officers who came on duty later that day said they had not been given any list although both were aware of a different prisoner who was being accommodated in a close supervision cell. As part of the OIP investigation, the Special Observation List was found on a separate landing in the prison.
The OIP said a broken window in the cell occupied by the deceased had provided him with an opportunity to secure a ligature and inflict self-harm.
It also noted that all broken cell windows in the Midlands Prison had been fixed by mid-2020 as part of the strategy to reduce self-harm in prisons and minimise access to ligature points.
The OIP said it was pleased to note that the IPS had reviewed its critical incident policy since the prisoner’s death but before the completion of its investigation to provide for a hot and cold debrief for incidents such as the death of a prisoner in custody.
The OIP issued a total of eight recommendations, of which all but one were either fully or partially accepted by the Irish Prison Service (IPS).
The IPS said it did not accept the OIP’s recommendation that prison staff should also record the names of prisoners on the Special Observation List in a Class Journal to ensure there was no doubt about which prisoners needed to be checked every 15 minutes.
The IPS said it would result in staff duplicating a list that was readily and easily available.
It said other recommendations which relate to the recording of prisoners placed on the Special Observation List and checks and assessments on them were already in place or being assessed.
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